This invention relates to a method of improving kidney function. More specifically, this invention relates to a method of improving the hydrostatic forces and hemodynamics of the kidney through the manipulation of pressures within the urinary collecting system.
A fundamental understanding of renal physiology can be readily found in the available medical literature, such as xe2x80x9cSection 6: Alterations in Urinary Function and Electrolytesxe2x80x9d, Harrison""s Principle of Internal Medicine, McGraw-Hill, 1994, 13th ed., p. 235-262. The main function of the kidneys is to maintain the constancy of the body""s internal environment by regulating the volume and composition of the extracellular fluids. To accomplish this, the kidneys balance precisely the intake, production, excretion, and consumption of many organic and inorganic compounds. This balancing requires that the kidneys perform several more specific functions.
One of the specific functions of the kidneys is the excretion of inorganic compounds. The renal excretion of sodium ion (Na+), potassium ion (K+), calcium ion (Ca++), magnesium ion (Mg++), hydrogen ion (H+), and bicarbonate ion (HCO3xe2x88x92) exactly balances the intake and excretion of these substances through other routes, for example, the gastrointestinal tract and the skin.
Another specific function of the kidneys is the excretion of organic waste products. Normally the kidneys excrete such waste products as urea and creatinine in amounts that equal their rate of production.
A third specific function of the kidneys is the regulation of blood pressure through the formation and release of renin. Renin is a major component of the reninangiotensinaldosterone mechanism which directly affects the tension in the walls of arteries. In addition, the reninangiotensinaldosterone mechanism also controls blood pressure by controlling body fluid volume.
A fourth function of the kidneys is the regulation of the production of erythrocytes through the formation and release of renal erythropoietic factor.
Finally, the last specific kidney function is the activation of Vitamin D. Vitamin D which is ingested must undergo two activation steps in the body before it can regulate calcium metabolism. The first activation step occurs in the liver, and the second occurs in the kidney.
An understanding of renal physiology requires familiarity with the anatomy of the kidney. The kidneys are located retroperitoneally in the upper dorsal region of the abdominal cavity and have bean-like shapes, as shown in FIG. 2. The concave curve or innermost part is called the renal pelvis, while the convex curve or outermost part is called the renal cortex. Between the cortex and the pelvis lies the renal medulla. The artery supplying the kidney is the renal artery, and the vein draining the kidney is the renal vein. The ureter, which drains the kidney of water, mineral and wastes, empties into the bladder, which in turn empties through the urethra. The renal artery, renal vein and ureter attach to the kidney at the renal pelvis.
On a microscopic level, each kidney is made up of approximately one million smaller units called nephrons. This basic functional unit of the kidney, as shown in FIG. 1, is composed of a glomerulus 10 with its associated afferent 12 (i.e., entering) and efferent 14 (i.e., exiting) arterioles and a renal tubule 16. The glomerulus 10 consists of a tuft of 20-40 capillary loops protruding into Bowman""s capsule 18, a cup-like shaped extension of the renal tubule which is the beginning of the renal tubule. The epithelial layer of Bowman""s capsule 18 is only about 400 xc3x85 thick, which facilitates passage of water and inorganic and organic compounds. In addition, the capillary endothelium is fenestrated (i.e., porous) with an incomplete basement membrane which further facilitates passage of water and inorganic and organic compounds. The renal tubule has several distinct regions which have different functions: the proximal convoluted tubule 20, the loop of Henle 22, the distal convoluted tubule 24, and the collecting duct 26 that carries the final urine to the renal pelvis and the ureter.
There are two basic types of nephrons, cortical nephrons and juxtamedullary nephrons. The cortical nephrons comprise about 85% of all nephrons in the kidney and have glomeruli located in the renal cortex. In addition, cortical nephrons have short loops of Henle which descend only as far as the outer layer of the renal medulla. The juxtamedullary nephrons are located at the junction of the cortex and the medulla of the kidney. Juxtamedullary nephrons have long loops of Henle, which penetrate deep into the medulla and sometimes reach the tip of the renal papillae. These nephrons are important in the counter-current system, by which the kidneys concentrate urine.
The constancy of the body""s internal environment is maintained, in large part, by the continuous functioning of its roughly two million nephrons. As blood passes through the kidneys, the nephrons clear the plasma of unwanted substances (e.g., urea) while simultaneously retaining other, essential substances (e.g., water). Unwanted substances are removed by glomerular filtration and renal tubular secretion and are passed into the urine. Substances that the body needs are retained by renal tubular secretion and are returned to the bloody by reabsorptive processes.
Glomerular filtration, i.e., the amount of fluid movement from the capillaries into Bowman""s capsule, is the initial step in urine formation. The plasma that traverses the glomerular capillaries is filtered by the highly permeable glomerular membrane, and the resultant fluid, the glomerular filtrate, is passed into Bowman""s capsule. Glomerular filtration rate (GFR) refers to the volume of glomerular filtrate formed each minute by all of the nephrons in both kidneys. The glomerular filtrate then passes along the renal tubule and is subject to the forces in the proximal convoluted tubule, the loop of Henle, the distal convoluted tubule and finally the collecting duct. The renal tubule functions either to secrete or reabsorb organic or inorganic compounds into or from the glomerular filtrate. Both of these renal tubular functions involve active transport mechanisms as opposed to passive transport mechanisms.
Glomerular filtration is proportional to the membrane permeability and to the balance between hydrostatic and oncotic forces. The hydrostatic pressure driving glomerular filtration is the gradient between intrarenal blood pressure and the pressure within the Bowman""s capsule (presumed to be approximately atmospheric). The intrarenal pressure is for all intents and purposes equivalent to the systolic and diastolic blood pressures measured peripherally. Since the intrarenal blood pressure in all living beings is greater than atmospheric pressure, the hydrostatic pressure can be conceptualized as the pressure driving fluid out of the glomerular capillary and into Bowman""s capsule. The colloid oncotic pressure gradient is the difference between the concentrations of particles on either side of a water permeable membrane through which the particles cannot pass. Since there are many particles within the capillaries that cannot pass through the-capillary endothelium including cells, platelet, and macromolecules, the colloid oncotic pressure gradient can be conceptualized as the pressure driving fluid into the glomerular capillary. When the hydrostatic pressure exceeds the oncotic pressure, filtration occurs. Conversely, when the oncotic pressure exceeds the hydrostatic pressure, reabsorption occurs.
In the body, the major determinant of GFR is the hydrostatic pressure within the glomerulus. In addition, the renal blood flow (RBF) through the glomeruli has a great effect on GFR; when the rate of RBF increases, so does GFR. There are several factors which control the RBF: (1) an intrinsic phenomenon observed in the renal capillaries called autoregulation, (2) sympathetic stimulation through the autonomic nervous system, and (3) arteriolar resistance.
The term xe2x80x9ckidney functionxe2x80x9d or xe2x80x9crenal functionxe2x80x9d generally refers to the kidneys"" ability to clear creatinine. Creatinine clearance normally declines with age, as does GFR. Thus, kidney function is generally synonymous with GFR. The decline in GFR with age is due to declines in renal plasma flow, cardiac output, and renal tissue mass.
Renal failure is divided into two main categories: (1) acute renal failure and (2) chronic renal failure. Acute renal failure (ARF) is the clinical condition associated with rapid, steadily increasing azotemia (elevated level of blood urea nitrogen (BUN)), with or without oliguria ( less than 500 mL/day of urine output). Chronic renal failure (CRF) is the clinical condition resulting from a multitude of pathologic processes that lead to derangement and insufficiency of renal excretory and regulatory function (uremia).
ARF is further subdivided into three diagnostic categories: (1) prerenal azotemia, which is due to inadequate renal blood perfusion, (2) renal azotemia, which is due to diseases or abnormal conditions within the kidney itself, and (3) postrenal azotemia, which is due to obstruction of kidney outflow either at the point of the ureters, the bladder or the urethra.
A great deal of research has focused on the effects of postrenal obstruction on renal hemodynamics, metabolism, and filtration/concentrating ability, perhaps because postrenal obstruction is a rather common clinical condition. Diseases which cause postrenal obstruction include: (1) kidney and ureteral stones, (2) cancers of the ureter, bladder, or prostate, and (3) congenital anomalies such as posterior urethral valves. In all of these disease entities, the common pathologic process is an obstruction to the flow of urine with a subsequent rise in pressure in the collecting system. It is well known that when this occurs, renal blood flow is diminished, renal blood flow is redistributed from cortex to medulla, glomerular filtration decreases, and tubular concentrating ability fails. However, there is no known research conducted or reported on the effects of negative pressure applied to the renal collecting system with respect to renal physiology and the parameters mentioned above.
Because, anatomically, the kidney is one of the few areas of the body where the intravascular space is in direct extension with the external atmosphere (i.e., the vascular endothelium of the glomerulus is porous and in direct contact with the Bowman""s capsule and tubules of the nephron which connect to the ureter, bladder, and ultimately the outside world via the urethra), the physiology of the kidney can be altered by changing the atmospheric pressure. It is therefore desirable to reduce the pressure at the outflow tract of the urinary system, i.e., the renal collecting system, below atmospheric pressure, which would then be transmitted to the level of the Bowman""s capsule to increase hydrostatic pressure and thereby increase glomerular filtration and kidney function.
Experimentation has been conducted in a swine model to confirm this hemodynamic affect of negative pressure on the collecting system of the kidney. Under direct vision with the kidney exposed, the venal collecting system was brought to xe2x88x9240 cm H2O pressure in four otherwise healthy pigs. Average blood pressure was found to fall by 16 mm Hg systolic and 12 mm Hg diastolic. Heart rate rose by an average of 14 bpm.
Although it is conceivable that a single-lumen conventional ureteral catheter could be used for this purpose, there are several problems which would likely arise. Most importantly, once the lumenal portion of a ureteral catheter is positioned in the renal pelvis and suction is applied to this catheter, the drainage holes of the catheter may become occluded if they are sucked up against the mucosa of the renal pelvis. This would interfere with the negative pressure applied to the ureteral catheter from transmitting to the level of the glomerulus.
It is an object of the invention to provide a method of improving kidney function.
It is also an object of the invention to provide a method of improving the hydrostatic forces and hemodynamics of the kidney through manipulation of pressures within the urinary collecting system.
It is a further object of the invention to provide a ureteral catheter with a retractable cage apparatus which would prevent the suction and entrapment of the urinary collecting system mucosa in its drainage holes.
These and other objects of the invention will become more apparent from the description below.
The present invention is directed to a method of increasing kidney function by reducing the pressure of the urinary outflow tract. The present invention is further directed to a method of treating renal failure caused by renal disease or urinary outflow obstruction by reducing the pressure of the urinary outflow tract. The present invention is also directed to an apparatus which is used to reduce the pressure of the urinary outflow tract and to a method of increasing kidney function by reducing the pressure of the urinary outflow tract in conjunction with a drug that increases renal blood flow. Lastly, the present invention is directed to a kit which is portable and convenient and which reduces the pressure at the urinary outflow tract to increase kidney function.